Incidence and risk of falls in patients treated for hematologic malignancies in the Intensive Hematology Unit

Objective: to determine the incidence and rate of risk of falls in adult patients treated for hematologic malignancies in the Intensive Hematology Unit of a reference hospital. Method: this is a retrospective observational study. A total of 101 patients were evaluated. The occurrence of falls was obtained from records of the unit and the predictive variables of the Hendrich II model were collected, namely: sex, presence of dizziness or vertigo, mental confusion, elimination problems, depression, use of benzodiazepines, use of anticonvulsants, and the Get up and Go test. Results: two fall events were reported in 101 patients (incidence of 1.98% over a 1.5-year period). Based on the cut-off point 5 of the Hendrich II Model, 30 patients (29.7%) were at risk of fall at the moment of hospital admission, 41 (40.6%) in the middle of the hospitalization period, and 38 (37.6%) at the moment of hospital discharge. Conclusions: patients treated for hematological malignancies presented low incidence and high risk of falls during hospitalization.


Introduction
Patient falls are still the most common of the adverse events reported in acute care centers, causing morbidity, mortality, fear of falling and prolonged loss of mobility, which may shorten people's life span (1)(2) .
Falls correspond to an event of high incidence in the hospital environment, with percentages between 1.1% and 22%, depending on the specificity of the patient (3) .
Three types of patient falls have been identified: and (c) unanticipated physiological (falls attributed to physiological factors that cannot be predicted before the first fall) (1) . Physiological falls in hospitals account for 78% of the total falls, and they have been, therefore, the focus of many investigations attempting to identify factors associated with risk of falls (4)(5) .
Patients hospitalized for cancer have even higher frequencies of falls, with a higher rate of injury, and greater severity when compared to hospitalized patients who do not have cancer (2,(6)(7)(8)(9) . About 23% to 42% of falls in patients hospitalized for cancer result in injuries, of which 2% to 9% end in severe events (fractures, subdural hematoma, excessive bleeding and death) (7,(9)(10)(11) .
In this context, presence of diagnosis of cancer is already considered a risk factor for falls during hospitalization (5) . Younger patients admitted to oncology units, intensive care units, and units of infectious diseases are at increased risk of falls (12) . The cancer patients with the highest risk of falls during hospitalization are those with hematologic malignancies, brain cancer with presence of metastasis, those receiving transfusion of blood products, those under administration of chemotherapy, and those who had complications during the hospitalization period (6) . Another more recent study identified the use of technical help, history of falls, and presence of fatigue as risk factors among hospitalized cancer patients (2) . guide was used to report observational studies (16) .  (4)(5) . This model also proved useful when applied in an emergency service to predict falls in the community and recurrences to the emergency service (20) .

Results
The mean age of the patients was 35.6 (SD = 13.6) years.

Incidence and risk of falls
Two fall events were reported in 101 patients, with an incidence rate of 1.98% over a period of 1.5 years. The two events occurred at the time the patients performed hygienic activities with excretion in the portable bathroom in the bedroom and bathroom.  Non-Hodgkin's Lymphoma 6 (5.9) 6 (6.

Discussion
It was found that patients treated for hematologic malignancies during hospitalization had a low incidence rate of falls (1.98%), which was within the percentages found in the international literature regarding hospitalized adult patients (1.1% -22.0%) (1,22) . It is possible that this low incidence rate is due to the fact that the patients were mainly young people (mean age in accordance with international recommendations (7,(23)(24) .
Thus, the daily assessment of the risk of falls in patients under treatment for hematologic cancer is recommended to identify patients at risk and to implement appropriate prevention measures with a multidisciplinary approach (25) . The low number of adverse events, such as in-hospital falls is an indicator of the quality of the nursing service (2) . at the patient's bedside (26) . It was shown that cancer hospitalization period (40.6%) compared to admission (29.7%) and hospital discharge (37.6%). These results are similar to those obtained in another study (22) . This can be explained by aggressive treatments that patients receive, such as chemotherapy for induction, consolidation or transplantation of hematopoietic progenitors, which produce important symptoms, including fatigue (28) , mucositis, nausea, diarrhea and vomiting, pain and lack of appetite (29) . In addition, infections that produce febrile neutropenia (prevalence around 40%), a condition that prolongs hospitalization, delays new cycles of chemotherapy, and even increases mortality, is common in these patients (30) .
In this study, a significant association between the presence of dizziness at hospital admission and the occurrence of falls during hospitalization was identified.
In addition, dizziness was found to be more present in the middle (30.7%) and at the end of hospitalization (28.7%), when compared to hospital admission (21.8%).
Dizziness has been identified as a risk factor associated with falls in the hospital context (31) . In patients treated for hematologic malignancies during hospitalization, dizziness is a symptom that may be present and be during hospitalization (36)(37) . A recent study of 768 people hospitalized with cancer in China found that the use of drugs that affect the central nervous system (hypnotics, sedatives, serotonin inhibitors, opioids, antiepileptics and antipsychotics) increased by 4.29-fold the likelihood of suffering a fall event (38) .
The risk of falling in younger patients hospitalized for cancer may be associated with recurrent elimination needs (8,11) . These patients usually present urinary incontinence, diarrhea or urinary urgency, and these things can significantly increase the possibility of falls, as they use to occur mainly near the patient's bed, in the bathroom or in the corridor (23,39) .
Regarding the place of the falls, in the present study, it was identified that the two events occurred in the bedroom and in the bathroom during hygiene of excretion activities. This agrees with other studies that indicate the room as the place with the highest frequency of falls (80.4%), followed by the bathroom (17.1%) (23,26,39) .
Regarding the mobility evaluated with the Get up and Go test, a few patients were able to stand up alone in the first attempt at hospital admission (37.6%) and this frequency was even lower at the middle of the hospitalization (17.8%), and at hospital discharge (15.8%). A retrospective study of onco-hematologic patients showed that falls were strongly associated with mobility deficit and loss of independence in daily activities (32) . In particular, patients who undergo transplantation of hematopoietic progenitors are pretreated with chemotherapy, and during the course of hospitalization, they receive more chemotherapy with a high potential to cause peripheral neuropathy, which can lead to muscle weakness with motor function and walking (32,40) . Patients undergoing allogeneic transplantation, those with host-to-graft disease, as the first line agent are usually treated with high doses of corticosteroids for prolonged periods, which have been associated with myopathy and increased risk of falls (41)(42) .
In this context, it is suggested that, for the prevention of risk of falls, besides traditional measures, the nursing teams in intensive hematology units integrate other strategies that complement the care plans by other professionals, such as occupational therapists and kinesiologists (physical therapists), promoting interventions to maintain the motor skills necessary to perform the activities of daily living (24,43) .
A study of nurses in a hospital identified that among the fall prevention activities, the most frequently applied were: identification of cognitive deficits and risk factors, and caring for mobility and transfer of patients (44) . On the other hand, activities related to infrastructure, such as the use of guardrails, alarm systems and call lighting, are carried out on a smaller scale (44) . Some technological tools, such as motion sensors, that detect when patients get out of bed and there is risk of falling, which have been tested in hospitals and found to be useful (45) .
Although patients with hematologic and cerebral cancer have been identified as the oncology population most vulnerable to falls in the hospital context (6) , there is This study has as strong point the fact that it was conducted at the national referral center for treatment of hematologic malignancies, with a very specific population, which is treated with international standards of care. It was a pioneering study in our country that contributes to a better knowledge of the population treated for hematologic malignancies and of the use of a tool for evaluation of risk of falls that is more specific for this population, unique in the hospital context.

Conclusion
The incidence rate identified in this study (1.98%), although seemingly low, suggests the need for greater attention from the health team to strengthen the planning of prevention strategies with an interdisciplinary approach that promotes patient safety.
In this study, it was found that a significant